REM sleep behavior disorder RBD

1
REM sleep behavior disorder(RBD)

• Thomas Paparrigopoulos
• Athens University Medical School
• Department of Psychiatry, Sleep Research Unit,
• Athens, Greece

2
Parasomnias

• undesirable, unexpected, abnormal behavioural
  phenomena that occur during sleep
• primary and secondary parasomnias
• primary parasomnias
• REM parasomnias
• NREM parasomnias
• miscellaneous parasomnias

3
Definition of RBD

• RBD is characterized by the intermittent loss of
  REM sleep elecromyographic (EMG) atonia and by
  the appearance of elaborate motor activity
  associated with dream mentation (ICSD-Revised)

4
Clinical features of RBD (I)

• Prevalence 0.5
• Predominantly males ( 90 )
• Mean age at onset 6th-7th decade
• Probable prodromal history (for several years) of
  sleep talking, yelling, or limb jerking / Dream
  content may become more vivid, unpleasant,
  violent, or action-filled
• Excessive daytime sleepiness if sleep is
  sufficiently fragmented

5
Clinical features of RBD (II)

• Chief complaints
• Sleep injuries (lacerations, ecchymoses,
  fractures) ( 75 )
• Sleep disruption ( 20 )
• Altered dream process and content (gt 90 )
• Dream enacting behaviors i.e. talking, laughing,
  yelling, swearing, gesturing, grabbing, punching,
  kicking, sitting, jumping out of bed, running,
  etc., often violent and injurious (gt 90 )
• Periodic and non-periodic movements of limbs
  during NREM sleep (gt 50 )
• There is no activation of the autonomic nervous
  system during the episodes

6
Clinical features of RBD (III)

• Arousal from sleep to alertness and orientation
  is rapid and there is complete dream recall,
  which usually is appropriate to the observed
  behavior
• Comorbidity with other sleep disorders (e.g.
  sleep terrors, sleepwalking, narcolepsy) is not
  infrequent
• Frequency of episodes less than once per year to
  4 episodes per night
• Severity criteria (mild moderate severe)
  according to the frequency of RBD episodes, the
  degree of discomfort caused, and the implications
  for the patient and his bedpartner

7
Polysomnographic findings (I)

• The overall night sleep architecture is usually
  normal
• During REM sleep, affected individuals display
  excessive augmentation of muscle tone (chin EMG
  and / or limb phasic EMG twitching)
• Prominent and often prolonged periods of activity
  of the extremities
• These motor phenomena may be complex and highly
  integrated and often are associated with
  emotionally charged utterances

8
Polysomnographic findings (II)

• Absence of epileptic activity in association with
  the disorder
• In NREM sleep, periodic movements involving the
  legs, and occasionally the arms, and periodic
  movements of all extremities have been reported
• There is frequently a pronounced increase in REM
  density
• Increase in percentage of slow-wave sleep (SWS)

9
(No Transcript)
10
(No Transcript)
11
Etiology (I)

• Idiopathic RBD ( 60 )
• Symptomatic RBD (40 )
• Acute
• Withdrawal (alcohol, meprobamate, nitrazepam) or
  Intoxication (biperiden, tricyclic
  antidepressants, MAOIs)
• Chronic
• Medications (TCAs, SSRIs, SNRIs,
  anticholinergics, etc.)
• Cerebrovascular causes (hemorrhage, ischemic)
• Tumors (esp. of the pontine area)

12
Etiology (II)

• Neurodegenerative diseases
• Parkinsons disease
• Dementia (Alzheimers disease, Lewy body disease,
  corticobasal degeneration)
• Olivopontocerebellar degeneration
• Multiple system atrophy
• Amyotrophic lateral sclerosis
• Other causes (narcolepsy, familial, etc.)

13
RBD and Neurodegenerative Disorders

• May be a prodromal manifestation of Parkinsons
  disease, multiple system atrophy, etc.
• May antedate other symptoms by more than 10 years
• More than 1/3 of idiopathic RBD eventually
  develop Parkinsons disease
• Very common in multiple system atrophy (up to 90
  may present with REM without atonia RWA, and
  70 may have clinical RBD)
• Reports of Lewy body disease in several cases of
  idiopathic RBD (postmortem findings)
• Selegiline may trigger RBD in patients with PD
• Cholinergic treatment of Alzheimers disease may
  trigger RBD

14
Pathophysiology of RBD (I)

• REM sleep atonia and locomotor inhibition are
  active processes involving two distinct
  mechanisms
• Generators of these processes are located mainly
  in the pontine area
• An identical syndrome (absence of REM atonia and
  concurrent motor activity) is seen in cats with
  experimentally induced bilateral peri-locus
  coeruleus lesions (pontine area).
• Very few autopsy studies have been reported in
  humans
• Extensive neurologic evaluations in humans
  suffering from both the idiopathic and
  symptomatic forms have not identified specific
  lesions
• Findings in some patients suggest that diffuse
  lesions of the hemispheres, bilateral thalamic
  abnormalities, or primary brain-stem lesions may
  result in RBD

15
(No Transcript)
16
Pathophysiology of RBD (II)

• RBD is likely to result from either loss of REM
  atonia (due to functional depression or
  destruction of the responsible brainstem
  structures) or excessive locomotor activity (due
  to reduced activity or destruction of brainstem
  monoaminergic structures responsible for
  inhibiting locomotor phasic activity), or both

17
Differential Diagnosis of RBD

• Confusional arousals
• Sleepwalking
• Night terrors
• Sleep-related seizures
• Nocturnal panic attacks
• Periodic limb movement disorder
• Obstructive sleep apnea
• Post-traumatic stress syndrome - Nightmares
• Dissociative disorder
• Cardiopulmonary and gastrointestinal disorders

18
Diagnostic workup

• Detailed history of the sleep-wake complaints
• Thorough medical, neurological and psychiatric
  history and examination
• Screening for alcohol / substance use
• Recording of medication
• Standard polysomnographic recording with
  continuous overnight videotaping
• Multiple sleep latency test (when there is also a
  complaint of daytime fatigue and / or sleepiness)
• A brain imaging study (CT- scan, MRI) is
  mandatory if there is suspicion of an underlying
  brain disease.

19
Treatment of RBD

• Safety measures
• Clonazepam (0.5 2.0 mg at bedtime)
• Melatonin (3 12 mg / night)
• Carbidopa / L-dopa
• Clonidine
• Carbamazepine and Gabapentin
• Tricyclic antidepressants and MAOIs
• Other agents (pramipexole, donepezil, triazolam,
  clozapine, quetiapine)

20
Conclusion

• RBD represents an interesting, often overlooked
  parasomnia that reflects dysfunction in REM sleep
  control and expands our knowledge on the
  different states of being and their possible
  dissociation
• It may be useful for the understanding of certain
  neurodegenerative disorders
• Effective treatment for this disorder exists

21
(No Transcript)
22
(No Transcript)
23
Clinical features of RBD (III)

• Severity Criteria
• Mild REM sleep behavior occurs less than once
  per month and causes only mild discomfort for the
  patient or bedpartner.
• Moderate REM sleep behavior occurs more than
  once per month but less than once per week and is
  usually associated with physical discomfort to
  the patient or bedpartner.
• Severe REM sleep behavior occurs more than once
  per week and is associated with physical injury
  to the patient or bedpartner.

24

• Diagnostic criteria for REM sleep behavior
  disorder (ICSD 780.59-0)
• The patient has a complaint of violent or
  injurious behavior during sleep
• B. Limb or body movement is associated with dream
  mentation
• C. At least one of the following occurs
• 1. Harmful or potentially harmful sleep behaviors
• 2. Dreams appear to be acted out
• 3. Sleep behaviors disrupt sleep continuity

25
D. Polysomnographic monitoring demonstrates at
least one of the following electrophysiologic
measures during REM sleep 1. Excessive
augmentation of chin electromyographic (EMG)
tone 2. Excessive chin or limb phasic EMG
twitching, irrespective of chin EMG activity and
one or more of the following clinical features
during REM sleep a. Excessive limb or body
jerking b. Complex, vigorous, or violent
behaviors c. Absence of epileptic activity in
association with the disorder E. The symptoms
are not associated with mental disorders but may
be associated with neurologic disorders F. Other
sleep disorders (eg, sleep terrors or
sleepwalking) can be present but are not the
cause of the behavior Minimal Criteria B plus C